Doctor of Philosophy
Bruce Rybarczyk, PhD
Introduction: Family physicians provide access to medical and behavioral healthcare for many underserved populations. Integrating behavioral health clinicians into primary care practices has been proposed as one of the most effective ways to increase access to necessary behavioral health services for many Americans. Integrated behavioral healthcare (IBHC) has begun to be implemented in family medicine practices but there is limited research examining the impact for patients and clinic staff. This study begins to fill this gap in the literature by examining the effects of implementing integrated behavioral healthcare in an urban family medicine clinic in a medically underserved area.
Objective: The objective of this study is to describe patients who use IBHC services, examine behavioral health outcomes, and study patient and staff satisfaction with IBHC services. This is done in the context of the Quadruple Aim of Healthcare which purposes to improve population health, provide a better patient experience, create smarter healthcare spending, and improve medical staff work quality of life. Aspects of implementation are addressed as well, namely the appropriateness, acceptability, adoption, feasibility, and penetration of IBHC services.
Methods: IBHC services were introduced to an urban family medicine clinic in a medically underserved area with a census of greater than 4,500 patients (56.17% African American, 24.4% White, 1% Asian, 22.9% Latino/a; 33.3 % Children under 18). Using information from medical records, a description and comparison of the general clinic population and those that use IBHC services is provided. Behavioral health outcomes were measured by tracking patient anxiety and depression over time, from initial session through follow-up at least 3 months after their final session for a subset of patients. Patient and clinic staff satisfaction were assessed using qualitative and quantitative methods. Supplemental analysis compare behavioral health outcomes against a previous sample of patients from the same clinic before IBHC services were present.
Results: Demographic information is presented and compared to highlight the unique difference between race/ethnicity, age, and gender. This study showed that adult patients experienced a significant reduction over time from initial session to follow-up with regards to anxiety, F(1.77, 130.63) = 65.65, p < .001, and depression, F(1.78, 131.68) = 37.88, p < .001. Patient interviews and surveys were analyzed and found that patients generally reported high satisfaction with IBHC services and found their behavioral health needs where addressed in the way they wanted them to be. Finally, medical staff reported high satisfaction with IBHC services and reported that they had reduced stress, increased comfort in caring for patients with behavioral health needs, and improved work quality of life.
Discussion: IBHC services were implemented at a family medicine clinic with a population that is overrepresented by minorities and uninsured patients. This study showed that implementation of IBHC addressed components of the Quadruple Aim of Healthcare, namely improvement of population health, enhanced patient experience, and improvement of clinic staff work life. IBHC services were found by patients and staff to be acceptable, appropriate, and feasible. Further, this study demonstrated the ability of a clinic to adopt IBHC services with sufficient penetration (10.8% of patients received at least brief services) after 2 years. Implications for practice and research and future directions are also discussed.
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